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ORIGINAL RESEARCH

Undergraduate nursing students’ knowledge and

attitude regarding pain management of children in
Upper Egypt
∗1
Marzoka Abd El-Aziz Gadallah1 , Atyat Mohammed Hassan , Soad Abd El-Hamied Shargawy2
1
Pediatric Nursing Department, Faculty of Nursing, Assiut University, Egypt
2
Community Health Nursing Department, Faculty of Nursing, Assiut University, Egypt

Received: November 10, 2016 Accepted: December 18, 2016 Online Published: February 7, 2017
DOI: 10.5430/jnep.v7n6p100 URL: http://dx.doi.org/10.5430/jnep.v7n6p100

A BSTRACT
Pain assessment and management require nurses to be equipped with adequate knowledge and proper attitudes. This research
aimed to assess undergraduate nursing students’ knowledge and attitude regarding pain management in children. Descriptive
cross-sectional research design was utilized. This work was implemented at Faculty of Nursing in Assiut University. The study
subjects consisted of convenient sample of undergraduate nursing students at third and fourth year during the academic year
2015-2016. One tool was used for this study consisted of two parts: part I: Demographic questionnaire, and part II: Pediatric
Nurses’ Knowledge and Attitudes Survey Regarding Pain (PNKAS). Fifty-six percent of undergraduate nursing students had
unsatisfactory score regarding PNKAS. The highest percentage 76.2% of participating students had less than 50% of total score
of knowledge and attitude regarding pain especially to pharmacological information. The study concluded that nursing students
had poor knowledge and attitude regarding pain management by using PNKAS especially in the part of pain assessment and
pharmacological pain management. The more contact with pediatric patients the higher the knowledge and positive attitudes
among undergraduate nursing students. The study recommended that the pediatric staff should review the curriculum to enrich
more about assessment and management of pain.

Key Words: Undergraduate nursing student, Knowledge, Attitude, Pain management

1. I NTRODUCTION and behavioral consequences for the child.[1, 2] According to

Mathews (2011), forty percent of children complain of acute
Pain is a major source of distress for children and their fam-
pain while chronic pain affects at least 15%-20%.[3]
ilies as well as health care providers. Children may experi-
ence pain as a result of surgery, injuries, acute and chronic One of the important responsibilities of health care personnel
illnesses, and medical or surgical procedures. It can lead is to relieve pain as possible. It is unethical to let the child
to serious physical and emotional consequences such as in- suffer from pain without any trials to relieve pain or provide
[4]
creased oxygen consumption and alterations in blood glucose high-quality treatment. This comes in the same line with
[5]
metabolism. In addition, the experience of untreated pain the American Pain Society (1995) which labeled the pain
early in life may lead to long term physiologic, psychological as “the fifth vital sign” to emphasize the importance of as-
∗ Correspondence: Atyat Mohammed Hassan; Email: atyathassan@aun.edu.eg; Address: Pediatric Nursing Department, Faculty of Nursing, Assiut

University, Egypt.

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sessing pain frequently and providing appropriate treatment. Plaisance and Logan (2006)[14] and Goodrich (2006)[15] who
The goal is to encourage health care professionals to assess concluded that there are a large gaps in knowledge and mis-
pain every time and to institute measures to manage it.[6] conceptions regarding opioids, addiction, dose of analgesic,
difference between addiction, dependence and tolerance, and
A research conducted by Chin Tracy (2007)[7] to assess nurs-
opioid side effects.
ing students’ knowledge and attitudes regarding pediatric
pain at California State University, concluded that many Nurses play an important role in assessing and managing
complex and interrelated factors that have participated to children’s pain during hospitalization. They spend most of
the undertreatment of pediatric pain, including professionals’ their time at the patient’s bedside as compared to other health-
misconceptions about pain and its management; limited clin- care professionals; they perform an instrumental role in the
ical information regarding pain control and analgesic usage; assessment and evaluation of pain. Therefore, they must
persistent myths discounting a child’s ability to experience become the primary agents of change for better pain manage-
pain; the complexities of pain assessment in children, par- ment outcomes within patient populations.[16] Consequently,
ticularly nonverbal children; and the lack of awareness of if student nurses are insufficiently educated and ill prepared
the detrimental effects of unrelieved pain related to illness or to effectively relieve pain, the patient ultimately suffers. For
medical care. Two of the most common misconceptions held this reason, undergraduate nursing students must be well
by student nurses contributing to the undertreatment of pe- educated and knowledgeable about pain and its management
diatric pain are the fears related to depression and addiction to improve patient outcomes and collaborate efficiently with
from opioid treatments. other healthcare professionals to successfully manage pain.
Children and their families have the right to receive pain
management that is both timely and effective. The accurate 1.1 Significance of study
assessment and effective management of a pediatric patient’s Undergraduate nursing students’ knowledge and attitudes
pain is a vital nursing activity requiring a nurse who possess toward pain management in children affect nursing care.[16]
an accurate theoretical knowledge base of pain, its assess- Hence, implementing these roles necessitate that nursing stu-
ment, management and appropriate attitudes unmarred by dents achieve a comprehensive solid knowledge of pain and
myths. The assessment of nursing students’ knowledge and its management in the undergraduate nursing program. Also,
attitudes may bring to light information that may assist in how to transfer these behaviors learned from pain manage-
the development of appropriate strategies to address educa- ment education into the clinical setting.[14] If student nurses
tional needs related to pediatric pain assessment and man- have poor knowledge and inadequate training to assess and
agement.[7] Some studies in Jordan have indicated that the mange pain, the patient ultimately suffers. In addition, many
student nurse has poor knowledge of pain and management studies conducted to assess and apply different types of pain
skills among children.[8, 9] Although scientific knowledge management actually on pediatric patients. On the other hand
about children’s pain is increasing, the undertreatment of no studies were conducted to assess knowledge and attitude
pediatric pain is still a serious problem.[10] It can delay heal- of undergraduate nursing students on pain management skills
ing and may develop into chronic pain.[11] Under-treated in Egypt.
chronic pain can limit daily activities, increase disability,
negatively affect the quality of life, create suffering, cause
anxiety, depression, anger, and fear, and increase the risk for 1.2 Aim of the study
suicide.[12] This study aimed to assess undergraduate nursing students’
knowledge and attitudes regarding pain management in chil-
In a study implemented by Duke et al. (2013)[13] on pain
dren.
management knowledge and attitudes of baccalaureate nurs-
ing students from the University of Texas at Tyler College of
Nursing & Health Sciences, it was found that; nursing faculty 1.3 Research questions
is in a unique position to significantly address the problem (1) What are the current knowledge and attitudes regard-
of pain management through facilitating the acquisition and ing pain management among undergraduate nursing
utilization of knowledge by the next generation of nurses students?
who are now undergraduate nursing students. Studies also in- (2) Are there relationships between demographic charac-
dicated that having faculty students who are knowledgeable teristics of undergraduate nursing students and their
about pain management was an important resource. Also, knowledge and attitudes regarding pain management?
these studies applied for undergraduate nursing students by

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2. S UBJECTS AND METHOD et al. (2015)[19] and Laprise (2016).[20] Also, Duke et al.
2.1 Design (2013),[13] Al-Khawaldeh et al. (2013)[9] and Al Omari
Descriptive cross-sectional research design was utilized. (2016)[8] who have found it a suitable tool for use with un-
dergraduate nursing students because it was reliable. Test
2.2 Setting re-test reliability (r = 0.67), Cronbach’s alpha was 0.75 and
This work was implemented at Faculty of Nursing in Assiut valid.
University in Upper Egypt. It is a governmental educational
institution. It was established in 1982, offers Bachelor de-
2.6 Procedure
gree in nursing science. The study period is five years; four
of these are academic study at the faculty and the last fifth Research proposal was approved by Ethical Committee in
year is clinical training year under the faculty staff supervi- the Faculty of Nursing. An official permission to collect
sion. English is the language of teaching and learning for the data was obtained from the Dean of Faculty of Nursing, As-
students in this institution. siut University. Written consent was obtained from students
who were willing to participate in the study, after explaining
2.3 Study participants nature and aim of the study. A pilot study was carried out
A convenient sample of third and fourth year nursing stu- on (10%) of nursing students who were excluded from the
dents who had studied pediatric nursing curriculum in the sample. It was conducted to assess clarity of the tool and
second semester of the academic year 2015-2016 were en- time needed to fulfill the tool. As the result of the pilot study,
rolled. The researchers distributed 510 questionnaires, 22 of there was no modification needed.
them didn’t return the questionnaires and 17 returned incom- The researcher collected data in the first semester of the aca-
plete questionnaires which were excluded, the total sample demic year 2015- 2016, for fourth year students and in the
was 471. end of second semester for third year students after finishing
the pediatric course, the student took about 25-35 minutes
2.4 Sample size
to fill the questionnaire. The researchers used the question-
It was calculated by (Epi-Info 6.04d) with a 95% confidence
naire in its English version as it was the students’ language
level using the sample size equation for estimation of single
of study at faculty of nursing. The scoring system of nurs-
proportion. The optional sample size was 375. The actual
ing students’ PNKAS; the correctly answered question was
sample increased to 471 students to compensate any dropout.
scored 1 point, and the incorrect zero point. The total score
of this knowledge was converted into a percent score. A
2.5 Tools of data collection
student who attained 50% of the total score was considered
One tool was used for this study which included two parts:
having satisfactory knowledge, while a score of less than
Part I: Demographic questionnaire which included: age, 50% was considered unsatisfactory.[14]
gender, residence, academic year, last qualifications before
entering the faculty, highest degree attained in nursing in
the last year, work in private setting, and attending any pain 2.7 Statistical analysis
management courses, seminars or lectures. Data entry was done using SPSS version 16.0 statistical soft-
Part II: Pediatric Nurses’ Knowledge and Attitudes Survey ware package. It was presented using descriptive statistics as
Regarding Pain (PNKAS), it consisted of 42-item inventory Mean and standard deviation, frequencies and percentages
developed by Manworren (2000)[17] as a modification of Mc- variables were compared using chi-square test. Statistical
Caffery and Ferrell’s (1997)[18] for use with pediatric nurses. significance was considered at p-value < .05.
It is a self-administered survey assessing nurses’ knowledge
and attitudes regarding pain management. It included pain
assessment and the use of analgesics and non-pharmacologic
3. R ESULTS
interventions for pain in the pediatric population. The sur- Table 1 showed that more than half (57.1%) of students, their
vey includes 25 true or false questions, 13 multiple choice age ranged from 22-23 years and the majority (93.4%) of
questions, and two-part case study questions. The PNKAS them were females. More than two-thirds (69.6%) of stu-
was selected for use in the study after thorough review of dents lived in rural area and only (11.9%) of them worked
literature on knowledge and attitudes toward pain and pain in private hospital during summer holiday and more than
management in the pediatric population by many researchers half of students (56.3%) didn’t attend any pain management
as: Chin Tracy (2006),[7] Chiang et al. (2006),[16] Ortiz courses, seminars or lectures.
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Table 1. Characteristics of undergraduate nursing students their total score of PNKAS except for those who were work-
Items N (%) ing at private hospital during summer holiday with p = .002.
Age/Years Figure 1 showed that more than half of the studied sample
21-↓22 202 (42.9) (56%) was having unsatisfactory knowledge level.
22-23 269 (57.1)
Figure 2 revealed that the highest percentage 76.2% of the
Total 471 (100)
undergraduate nursing students answered less than 50% of
Mean ± SD 21.73 ± 0.73
total items of PNKAS correctly.
Gender
Male 31 (6.6) 4. D ISCUSSION
Female 440 (93.4) Pain is the first complaint of any medical or surgical prob-
Total 471 (100) lems of infant or child. Therefore, it is one of the important
Residence duties of health care professionals to relieve pain and suffer-
Rural 328 (69.6) ing as possible. Relieving children’s pain has been perceived
Urban 143 (30.4) as a vital public health issue that needs immediate global at-
Total 471 (100) tention since failing to manage pain can lead to economic and
Academic year human burden on patients, their families, and society.[21, 22]
Third 183 (38.8)
This study aimed to assess undergraduate nursing students’
Fourth 288 (61.2)
knowledge and attitude as regard pain management in chil-
Total 471 (100)
dren. The results revealed that more than half of nursing
Last qualifications before entering the faculty
students’ knowledge and attitudes about pain management
General Secondary School 325 (69)
was unsatisfactory as shown in Figure 1 and more than three-
Technical Institute of Health or Nursing 146 (31)
quarters of undergraduate nursing students, their score re-
Total 471 (100) sponse to PNKAS questions were less than 50% as shown
Highest degree attained in nursing in the last year in Figure 2. These results were in agreement with Al Omari
Pass 10 (2.1) Omar (2016)[8] and Al-Khawaldeh et al. (2013)[9] who stated
Good 116 (24.6) that nursing students’ knowledge of and attitudes toward
Very good 232 (49.2) pain in Jordan is far from optimal. And also, the same find-
Excellent 113 (24.1) ings were obtained from previous studies of Latchman Jes-
Total 471 (100) sica (2010),[23] Chiu et al. (2003),[24] Rhimi-Madiseh et al.
Working in private hospital during summer holiday (2010),[25] Lunsford (2014),[26] Chow and Chan (2015)[27]
Yes 56 (11.9) and Plaisance and Logan (2006).[14]
No 415 (88.1)
Many factors contributed to nursing students’ poor knowl-
Total 471 (100)
edge and attitudes toward pain management. First, pediatric
Attending courses, seminars or lecture about pain
nursing course in Assiut University, faculty of nursing lacked
Yes 206 (43.7)
pediatric pain management theoretically and how to manage
No 265 (56.3)
it effectively in clinical practice. Second, students spend
Total 471 (100)
short time in clinical field with their patients and therefore
they have limited opportunity to assess or manage pain due
Table 2 illustrated that the highest percentage of the correct to increase number of students compared to staff.
answers was awarded for question number (22) with a per-
Hemsirelik Ulusal Çekirdek Egitim Program (HUCEP)
cent of (76.8%) followed by question number (8) with a
(2003)[28] added that there was no standards for the dura-
percent of 70.9%.
tion and content of pain management courses. The “National
Table 3 indicated that the highest percentage of the incorrect Core Curriculum Program for Nursing Education Standard-
answers as regard pharmacological information questions ization Commission” has made “pain management” an “es-
number (38, 26, 31, 39b) and pain assessment questions sential” part of the nursing curriculum. However Lai et al.
number (37, 39A, 1, 35). (2003)[29] stated that the trainers need to be experts in pain
Table 4 represented that there was no statistically significant management and the training subjects should be of adequate
differences between all items of students’ characteristics and duration with content that is appropriate for the pain manage-
ment applications encountered in the unit.
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Table 2. Frequency and percentages distribution of top ten correct answers of undergraduate nursing students
Question Students’
Items Key answer
Number answers (%)
Subsequent doses of opioid analgesics adjusted according to the child’s individual
22 True 362 (76.8)
response after first dose.
Giving maximum treatment of pain in the first procedure for children with
8 True 334 (70.9)
repeated painful procedure.
20 Religious beliefs of a child about pain and suffering are necessary. True 305 (64.7)
14 Presence of parents isn’t necessary during painful procedures. False 301 (63.9)
5 Similar stimuli give the same intensity of pain. False 299 (63.5)
10 Effect of oral acetaminophen 650 mg is nearly equal to oral codeine 32 mg. True 293 (62.2)
Severe pain is not affected by Ibuprofen and other non-steroidal anti-inflammatory
6 False 285 (60.5)
agents.
Children who have been using opioid analgesic more than one month rarely having
9 True 260 (55.2)
respiratory depression.
All of the
34 Choose which of these drugs are effective for the treatment of severe pain? 251 (53.3)
above
3 Distraction of children has negative effects on severe pain. False 247 (52.4)

Table 3. Frequency and percentages distribution of top ten incorrect answers of undergraduate nursing students
Question Students’
Items Key answer
Number answers (%)
38 Definition of narcotic/opioid addiction. < 1% 453 (96.2)
The recommended route of administration of opioid analgesics to children
26 Oral 442 (93.8)
with prolonged sever pain is:
37 What about the percentage of the child can report pain. 0-10 438 (93.1)
Marking on your record about his pain regarding your assessment of
39A 8 420 (89.1)
Andrew’s pain.
1 Severe pain must be changing vital signs False 411 (87.3)
The probability of the child developing clinically significant respiratory
31 < 1% 408 (86.6)
depression is:
35 The person who can evaluate the severity of child's pain accurately is. The child 398 (84.5)
Non-pharmacological pain management is effective in mild and moderate
7 False 393 (83.4)
pain while rarely useful in severe pain.
According to the child’s condition the pediatrician ordered “morphine IV 1-3 Giving morphine
39B 381 (80.9)
mg q1h PRN pain relief.” which action you will take at this time: 3 mg IV now.
Regarding to World Health Organization pain ladder recommendations
11 False 372 (79.00)
administering single analgesic agents rather than combining classes of drugs.

The first two items in the questionnaire were answered cor- about pain and suffering”. These findings can be explained
rectly by the majority of students “Subsequent doses of opi- in the light of the studied pediatric nursing curriculum which
oid analgesics adjusted according to the child’s individual focused on the importance of parents’ presence during hos-
response after first dose”. And “Giving maximum treat- pitalization of children. In addition, these items assessed
ment of pain in the first procedure for children with repeated attitudes, which rarely taught, but they are often adopted
painful procedure”. As represented in Table 2, these may be from supervisors. These results were supported by Stanley &
explained by the simplicity of these questions which can be Pollard (2013),[30] Ortiz et al. (2015)[19] and Al Omari Omar
easily expected by the students. (2016).[8]
The second two items answered correctly by the majority The present study also showed that nursing students had poor
of students were “Presence of parents isn’t necessary dur- knowledge and negative attitudes in the areas of pain assess-
ing painful procedures”. And “Religious beliefs of a child ment and pharmacological pain management, side effects and

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when time addiction of opioid can occur as shown in Table 3,
which obstructs ability of the student nurses for performing
pain assessment and management options for their pediatric
patients. This result agreed with Chiang et al. (2006)[16]
who stated items related to knowledge of pharmacological
treatment were the questions most frequently answered incor-
rectly by participants. A recent Jordanian study by Al Omari
Omar (2016)[8] found similar results when most undergrad-
uate Jordanian nursing students answered questions related
to pain assessment, pharmacological pain management and
when addiction can occur. In addition, Chow and Chan
(2010)[27] and Plaisance and Logan (2014)[14] stated that the
items with the poorest responses were related to medications
actions, side effects and administration. Also, Chiang et al.
(2006)[16] found that pharmacological management did not
increase after the educational program. Moreover, they have
shown that student nurses have a particularly poor under-
standing of basic pharmacokinetic principles and analgesic
agents.

Table 4. Relation between students’ characteristics and their total score

Total Score
Total
Students’ Characteristics Satisfactory level Unsatisfactory level χ2 p-value
Number
N % N %
Age (years)
21-↓22 202 86 42.6 116 57.4 0.283 .595
22-23 269 121 45.00 148 55.00
Residence
Rural 328 147 44.8 181 55.2 0.568 .451
Urban 143 60 41.9 83 58.1
Academic year
Third 182 78 42.8 104 57.2 0.155 .694
Fourth 289 129 44.6 160 45.4
Last qualifications before entering the faculty
General Secondary School 325 142 43.7 183 56.3 0.12 .913
Technical Institute of Health or Nursing 146 65 44.5 81 55.5
Highest degree attained in nursing in the last year
Pass 10 4 40.0 6 60.0
Good 116 52 44.8 64 55.2 4.465 .198
Very good 232 101 43.5 131 56.5
Excellent 113 48 42.5 65 57.5
Working in private hospital during summer holiday
Yes 56 33 60.00 23 40.00 9.337 .002
No 415 174 41.9 241 58.1
Attending courses, seminars or lecture about pain
Yes 206 95 46.1 111 53.9 0.861 .354
No 265 112 42.3 153 57.7

Figure 1. Percentage distribution of total score of

undergraduate nursing students
Figure 2. Percentage of undergraduate nursing students
who answered items of the PNKAS correctly

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These findings can be clarified in the light of the fact that stu- This may explain that, students who work in private hospitals
dent nurses generally were weak on pharmacological knowl- during the summer holiday took the responsibility to patient
edge. Furthermore, they have studied pharmacology in the care and the patients had the right to complain if any shorten-
first year 2 hours/week with no practical hours to strengthen ing occurred. So, students are encouraged to deal with many
the basic studied knowledge and when they reached the third patients, assessed their pain and learn how to manage it.
year, most of the information gained may be lost and they
didn’t remember it. It is worth mentioning that pain assess- 5. C ONCLUSION
ment or using pain scales not familiar to the student nurses
Nursing students had poor knowledge and attitudes as regard
in the pediatric nursing curriculum. Furthermore, method of
pain management when using PNKAS especially in the part
teaching during practical lessons in the pediatric nursing labs
of pain assessment and pharmacological pain management.
wasn’t prepared to simulate the real setting of the pediatric
Undergraduate student nurses who work in private hospitals
hospital as regard pain assessment and management.
during summer holiday had better knowledge and attitudes
An additional cause for the low scores in pain assessment compared to others. More than three quarters of undergradu-
knowledge in our study was the policy of Assiut University ate nursing students answered less than fifty percent of total
Children Hospital which didn’t permit the undergraduate items correctly.
nursing students to administer medications so there was no
experience regarding treatment or method of administration
6. R ECOMMENDATIONS
and doses of medications. The experience is limited to ob-
servations during clinical practice; this explanation was sup- (1) The pediatric nursing staff should review the curricu-
[31] [19]
ported by Kaki (2008), Oritz et al. 2015 and Al OMari lum and enrich it more about pain assessment and
(2016).[8] management.
(2) Preparing pediatric nursing labs with sufficient facili-
Concerning the relation between students’ characteristics ties to strengthen skills regarding pain assessment and
and undergraduate PNKAS total score, there was a statis- management.
tically significant difference as regard students working in (3) Interventional studies for preparing new graduate nurs-
private hospitals during summer holiday as presented in Ta- ing students with theoretical knowledge about pain,
ble 4. This result was in agreement with Stanley and pollard and its management in clinical practice with emphasis
(2013)[30] who indicated that there was a positive relationship on pharmacological and non-pharmacological inter-
between the level of knowledge and work experience. Pedi- ventions.
atric nursing experience correlated significantly with higher
(4) Teaching pharmacology course for nursing students of
knowledge levels. Meanwhile this result disagreed with Duke
the second year instead of the first year.
et al. (2008)[13] and Rahimi-Mediseh et al. (2010)[25] who
found that no significant difference was found between nurs-
ing students who had work experience related knowledge C ONFLICTS OF I NTEREST D ISCLOSURE
and attitude survey regarding pain (KASRP) scores. The authors declare that there is no conflict of interest.

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